Chapter 2
Anesthesia for Liposuction and Abdominoplasty
Gary Dean Bennett
2.1
Introduction
Since the development of the first outpatient surgical
program in 1966 and the first freestanding surgical
centers in 1969, the number of surgeries performed
outside of the hospital setting has dramatically in-
creased. An estimated 70 % of all elective surgery is per-
formed in an outpatient setting [1], and more than 50 %
of aesthetic plastic surgeons perform most of their pro-
cedures in an office setting [2].
The popularity of surgeries performed outside of
the hospital setting is a consequence of multiple fac-
tors. Clearly, economic considerations play a major role
in the shift to ambulatory surgery. Because of greater
efficiency, these outpatient surgical units have greater
cost-effectiveness [3]. Advances in monitoring capabil-
ities and the adoption of monitoring standards of the
American Society of Anesthesiologists (ASA) are cred-
ited for a reduction of perioperative morbidity and
mortality [4]. Advances in pharmacology have resulted
in a greater diversity of anesthetic agents with rapid on-
set, shorter duration of action and reduced morbidity
[5]. The advent of minimally invasive procedures has
further reduced the need for hospital-based surgeries.
Regulatory agencies such as the American Association
of Accreditation of Ambulatory Surgery (AAAASF) and
the Accreditation Association for Ambulatory Health
Care (AAAHC) have helped establish minimum stan-
dards of care for surgical locations where anesthesia is
administered. Ambulatory anesthesia has even become
a formal subspecialty of anesthesia with the establish-
ment of the Society of Ambulatory Anesthesia (SAM-
BA) in 1984. An evaluation of 1.1 million outpatients
revealed that the mortality rate after ambulatory anes-
thesia was 1.5 per 100,000 cases [6]. No deaths occurred
in 319,000 patients who were monitored in accordance
with ASA standards [7, 8].
As a consequence of the shift away from hospital-
based surgery, the surgeon has adopted a more impor-
tant role in the medical decision making process with
respect to anesthesia. Frequently, the surgeon decides
on the location of surgery, the extent of the preopera-
tive evaluation, the type of anesthesia to be adminis-
2
tered, the personnel to be involved in the care and mon-
itoring of the patient, the postoperative pain manage-
ment, and the discharge criteria used. Therefore, it is
incumbent on the surgeon to understand current stan-
dards of anesthesia practice. If the surgeon chooses to
assume the role of the anesthesiologist, then he or she
must adhere to the same standards that are applied to
the anesthesiologist. While the morbidity and mortali-
ty of anesthesia has decreased [9, 10], risk awareness of
anesthesia and surgery must not be relaxed.
2.1.1
The Surgical Facility
The surgeon is largely responsible for deciding in
which facility the procedure is to be performed. Surgi-
cal facilities may be divided into five main categories:
1. Hospital-based inpatient
2. Hospital-associated ambulatory surgical unit
3. Freestanding surgical center with short-stay
accommodation
4. Freestanding surgical centers without short-stay
accommodation
5. Office based operating rooms.
Each of these choices has distinct advantages and dis-
advantages. While convenient and economical, office
based surgery is associated with three times the mor-
tality of surgeries performed at other types of facilities
[11]. Ultimately, patient safety should be the para-
mount factor in the final decision. Patients with a risk
of ASA III undergoing major liposuction or large abdo-
minoplasty should preferentially be treated at hospital-
based or hospital-associated surgical units rather than
office-based operating rooms [12 – 14].
If the intended surgical procedure requires general
anesthesia or enough sedative-analgesic medication to
increase the probability of loss of the patient’s life pre-
serving protective reflexes (LPPRs), then, according to
the law in some states, the surgical facility must be ac-
credited by one of the regulatory agencies (AAAASF or
AAAHC) [15, 16].
Regardless of which type of facility is selected or the
type of anesthesia planned, the operating room must
30 2 Anesthesia for Liposuction and Abdominoplasty
be equipped with the type of monitors required to ful-
fill the monitoring standards established by the ASA
[17], as well as proper resuscitative equipment and re-
suscitative medications [18, 19]. The facility must be
staffed by individuals with the training and expertise
required to assist in the care of the patient [19, 20].
Emergency protocols must be established and re-
hearsed [21]. Optimally, the surgical facility must have
ready access to a laboratory in the event a stat laborato-
ry analysis is required. Finally, a transfer agreement
with a hospital must be established in the event that an
unplanned admission is required [18, 19].
2.1.2
Personnel
One of the most critical elements of successful surgical
outcomes is the personnel assisting the surgeon. Quali-
fied and experienced assistants may serve as valuable
resources potentially reducing morbidity and improv-
ing efficiency of the operating room [22, 23]. With an
office-based operating room the surgeon is responsible
for selecting the operating room personnel.
An anesthesiologist or a Certified Nurse Anesthetist
(CRNA) may administer anesthesia. The surgeon may
prefer to perform the surgery using exclusively local
anesthesia without parenteral sedation, especially in
limited liposuctions with the tumescent technique [24].
However, many surgeons add parenteral sedative or an-
algesic medications with the local anesthetic. If the sur-
geon chooses to administer parenteral sedative-analge-
sic medications, then another designated, licensed,
preferably experienced individual should monitor the
patient throughout the perioperative period [25]. Use
of unlicensed, untrained personnel to administer par-
enteral sedative analgesic medication and monitor pa-
tients may increase the risk to the patient. It is also not
acceptable for the nurse monitoring the patient to dou-
ble as a circulating nurse [26]. Evidence suggests that
anesthesia related deaths more than double if the sur-
geon also administers the anesthesia [27]. Regardless of
who delivers the anesthesia, the surgeon should prefer-
ably maintain current Advanced Cardiac Life Support
certification (ACLS) and all personnel assisting in the
operating room and recovery areas must maintain Ba-
sic Life Support Certification [28]. At least one ACLS
certified health provider must remain in the facility un-
til the patient has been discharged [29].
2.1.3
Preoperative Evaluation
The time and energy devoted to the preoperative prep-
aration of the surgical patient should be commensurate
with the efforts expended on the evaluation and prepa-
ration for anesthesia. The temptation to leave preoper-
ative anesthesia preparation of the patient as an after-
thought must be resisted. Even if an anesthesiologist or
CRNA is to be involved later, the surgeon bears respon-
sibility for the initial evaluation and preparation of the
patient. Thorough preoperative evaluation and prepa-
ration by the surgeon increases the patient’s confi-
dence, reduces costly and inconvenient last minute de-
lays, and reduces overall perioperative risk to the pa-
tient [30]. If possible, the preoperative evaluation
should be performed with the assistance of a spouse,
parent or significant other so that elements of the
health history or recent symptoms may be more readily
recalled.
A comprehensive preoperative evaluation form is a
useful tool with which to begin the initial assessment.
Information contained in the history alone may deter-
mine the diagnosis of the medical condition in nearly
90 % of patients [31]. While a variety of forms are avail-
able in the literature, a checklist format to facilitate the
patient’s recall is probably the most effective [32]. Re-
gardless of which format is selected, information re-
garding all prior medical conditions, prior surgeries
and types of anesthetics, current and prior medica-
tions, adverse outcomes to previous anesthetics or oth-
er medications, eating disorders, prior use of antiobesi-
ty medication, and use of dietary supplements, which
could contain ephedra, should be disclosed by the pa-
tient.
A family history of unexpected or early health con-
ditions such as heart disease, or unexpected reactions,
such as malignant hyperthermia, to anesthetics or oth-
er medications should not be overlooked. Finally, a
complete review of systems is vital to identifying undi-
agnosed, untreated, or unstable medical conditions
that could increase the risk of surgery or anesthesia.
Last minute revelations of previously undisclosed
symptoms, such as chest pain, should be avoided.
Indiscriminately ordered or routinely obtained pre-
operative laboratory testing is now considered to have
limited value in the perioperative prediction of mor-
bidity and mortality [33 – 37]. In fact, one study showed
no difference in morbidity in healthy patients without
preoperative screening tests versus a control group
with the standard preoperative tests [38]. Multiple in-
vestigations have confirmed that the preoperative his-
tory and physical examination is superior to laboratory
Table 2.1. Guidelines for preoperative testing in healthy pa-
tients (ASA 1 – 11). (Adapted from Roizen et al. [305])
Age Test
12 – 40a CBC
40 – 60 CBC, EKG
Greater than 60 CBC, BUN, glucose, ECG, CXR
a Pregnancy test for potentially childbearing females is sug-
gested
 2.1 Introduction 31

Table 2.2. Common indications for additional risk specific testing. (Adapted from Roizen et al. [306])
Electrocardiogram Chest X-ray Electrolytes, glucose, Urinalysis
liver function tests, BUN,
creatinine
History Coronary artery disease, congestive Bronchial asthma, con- Diabetes mellitus, chronic Diabetes mellitus,
heart failure, prior myocardial in- gestive heart failure, renal failure, chronic liver chronic renal dis-
farction, hypertension, hyperthy- chronic obstructive pul- disease, adrenal insuffi- ease, and recent
roidism, hypothyroidism, obesity, monary disease, pulmo- ciency, hypothyroidism, urinary tract in-
compulsive eating disorders, deep nary embolism hyperthyroidism, diuretic fection
venous thrombosis, pulmonary em- use, compulsive eating
bolism, smoking, chemotherapeutic disorders, diarrhea
agents, chemical dependency, chron-
ic liver disease
Symptoms Chest pain, shortness of breath, Chest pain, shortness of Dizziness, generalized Dysuria, urgency,
dizziness breath, wheezing, unex- fatigue or weakness frequency, and
plained weight loss, he- bloody urination
moptysis
Signs Abnormal heart rate or rhythm, hy- Cyanosis, wheezes, rales, Abnormal heart rate or
pertension, cyanosis, peripheral ede- rhonchi, decreased rhythm, peripheral ede-
ma, wheezing, rales, rhonchi breath sounds, peripher- ma, jaundice
al edema, abnormal
heart rate or rhythm

analysis in determining the clinical course of surgery

and anesthesia [39 – 43]. Newer guidelines for the ju-
dicious use of laboratory screening are now widely
accepted. Table 2.1 outlines a general approach for
healthy patients not taking medications. Additional
preoperative tests may be indicated for patients with
prior medical conditions or risk factors for anesthesia
and surgery (Table 2.2).
Consultation from other medical specialists should
be obtained for patients with complicated or unstable
medical conditions. Patients with ASA III risk designa-
tion should be referred to the appropriate medical spe-
cialist prior to elective surgery [25]. The consultant’s
role is to determine if the patient has received optimal
treatment and if the medical condition is stable. Addi-
tional preoperative testing may be considered neces-
sary by the consultant. The medical consultant should
also assist with stabilization of the medical condition in
the perioperative period if indicated. If the surgeon has
concerns about a patient’s ability to tolerate anesthesia,
a telephone discussion with an anesthesiologist or even
a formal preoperative anesthesia consultation may be
indicated.
Certain risk factors, such as previously undiagnosed
hypertension, cardiac arrhythmias, and bronchial
asthma may be identified by a careful physical exami-
nation. Preliminary assessment of head and neck anat-
omy to predict possible challenges in the event endo-
tracheal intubation is required may serve as an early
warning to the anesthesiologist or CRNA even if a gen-
eral anesthetic is not planned. For most ambulatory
surgeries, the anesthesiologist or CRNA evaluates the
patient on the morning of surgery.
2.1.4
Preoperative Risk Assessment
The ultimate goals of establishing a patient’s level of risk
are to reduce the probability of perioperative morbidity
and mortality. The preoperative evaluation is the cru-
cial component of determining the patient’s preopera-
tive risk level. There is compelling evidence to suggest
that the more coexisting medical conditions a patient
has, the greater the risk for perioperative morbidity and
mortality [25, 44]. Identification of preoperative medi-
cal conditions helps reduce perioperative mortality.
A variety of indexing systems have been proposed to
help stratify patients according to risk factors. One
such classification, first proposed in 1941 [45], later
modified in 1961 by Dripps [46], and finally adopted by
the ASA in 1984 (Table 2.3) [47], has emerged as the
most widely accepted method of preoperative risk as-
sessment. Numerous studies have confirmed the value
of the ASA system in predicting which patients are at a
higher risk for morbidity [48] and mortality [49 – 51].
Goldman and Caldera established a multifactorial in-
dex based on cardiac risk factors [52]. This index has
repeatedly demonstrated its usefulness in predicting
perioperative mortality [53, 54]. Physicians should in-
corporate one of the acceptable risk classification sys-
tems as an integral part of the preoperative evaluation.
Multiple authors have documented the association
between morbidity and mortality and the type of sur-
gery [55 – 58]. The consensus of these studies confirms
the increased risks of perioperative complications for
more invasive surgeries, surgeries with multiple com-
bined procedures, surgeries with prolonged duration,
and surgeries with significant blood loss [59]. While
32 2 Anesthesia for Liposuction and Abdominoplasty
Table 2.3. The American Society of Anesthesiologists’ Physical
Status Classification
ASA Class I A healthy patient without systemic medical
or psychiatric illness
ASA Class II A patient with mild, treated and stable
systemic medical or psychiatric illness
ASA Class III A patient with severe systemic disease that
is not considered incapacitating
ASA Class IV A patient with severe systemic, incapacitat-
ing and life threatening disease not neces-
sarily correctable by medication or surgery
ASA Class V A patient considered moribund and not
expected to live more than 24 h
studies correlating the amount of fat aspirate during li-
posuction or the amount of tissue removed during ab-
dominoplasty with perioperative morbidity and mor-
tality have not been performed, it would not be unrea-
sonable to extrapolate conclusions from the previous
studies and apply them to abdominoplasty and lipo-
suction. Liposuction surgeries with less than 1,500 ml
fat aspirate are generally considered less invasive pro-
cedures, while liposuctions aspirating more than
3,000 ml are considered major surgical procedures
[19]. As blood loss exceeds 500 cc [59], or the duration
of surgery exceeds 2 h, morbidity and mortality in-
crease [48, 60].
2.2
Anesthesia in Patients with Preexisting Disease
Over the past 30 years the morbidity and mortality of
surgery have steadily declined [10]. One hypothesis to
explain this decline has been the greater recognition of
preoperative risk factors and the improved periopera-
tive medical management of patients with coexisting
diseases. Surgeons who perform outpatient surgery, es-
pecially office-based surgery, and particularly those
surgeons who choose to administer sedative or analge-
sic medication, must appreciate how these medical
conditions may increase the risk of anesthesia in the
surgical patient. Furthermore, the surgeon should
maintain a current, working understanding of the eval-
uation and treatment of these medical conditions.
2.2.1
Cardiac Disease
Cardiac related complications, including myocardial
infarction and congestive heart failure, are the leading
cause of perioperative mortality [62, 63]. Most patients
with heart disease can be identified with a careful pre-
operative history and physical [64]. Since 80 % of all ep-
isodes of myocardial ischemia are silent [65, 66], a high
index of suspicion for silent ischemia must be main-
tained when assessing asymptomatic patients with risk
factors for heart disease, such as smoking, hyperten-
sion, diabetes mellitus, obesity, hyperlipidemia, or
family history of severe heart disease. Patients with
known cardiac disease must be evaluated by the inter-
nist or cardiologist to ensure the medical condition is
optimally managed. When anesthesia is planned, pa-
tients with significant heart disease should preferen-
tially undergo surgery at a hospital-based surgical unit
rather than a physician’s office.
Most studies have consistently demonstrated that
patients who have suffered previous myocardial infarc-
tions have a dramatically greater risk of reinfarction
and death if surgery is performed less than 6 months af-
ter the cardiac event [67 – 69]. More recent studies sug-
gesting a lower rate of reinfarction [70, 71] involved pa-
tients who were hospitalized in the intensive care unit
with invasive hemodynamic monitoring. These studies
may not have relevance to patients undergoing elective
ambulatory surgery. At this time, the prudent choice
remains to postpone elective surgeries for at least
6 months after myocardial infarction.
Goldman et al. established a cardiac risk index [52]
which has been useful in identifying patients with in-
termediate risk for cardiac complications in the periop-
erative period [53]. Patients with a score greater than
13 should be referred to a cardiologist for preoperative
evaluation. Dipyridamole thallium scanning and dobu-
tamine stress echocardiography have proven useful in
predicting adverse perioperative cardiac events [72].
One reliable and simple screening method to evaluate
cardiac status is exercise tolerance. The ability to in-
crease the heart rate to 85 % of the age-adjusted maxi-
mal heart rate is a reliable predictor of perioperative
cardiac morbidity [73].
Despite years of investigation, no one anesthetic
technique or medication has emerged as the preferen-
tial method to reduce the incidence of perioperative
complications in patients with cardiac disease [74, 75].
Regardless of which anesthesia technique is selected,
scrupulous monitoring should serve as the framework
for safe anesthetic management. Hemodynamic fluctu-
ations must be avoided to prevent ischemic episodes in
the perioperative period.
2.2.2
Obesity
The current prevalence of obesity in the USA is esti-
mated to be 55 % of the population [76]. It is reasonable
to assume that patients undergoing major liposuction
or abdominoplasty have a greater incidence of obesity.
The most widely accepted method of quantifying the
level of obesity is the body mass index (BMI), which is
determined by weight (kg)/height (m)2. Patients with a

BMI over 30 are considered obese, while a BMI over 35
indicates morbid obesity [77].
The risk factors associated with obesity such as dia-
betes mellitus, hypertension, heart disease, sleep ap-
nea, and occult liver disease [78] should concern clini-
cians administering anesthesia to patients with obesity.
A thorough preoperative evaluation must rule out these
occult risk factors prior to elective surgery.
Anatomical abnormalities make airway control
challenging [79] and endotracheal intubation hazard-
ous [80]. The combination of a higher gastric volume
and lower pH with a higher frequency of esophageal re-
flux results in a higher risk of pulmonary aspiration
[81]. Pulmonary function can be severely restricted
even in an upright position [82]. However, in the supine
position, pulmonary function is further reduced [83].
Pulmonary function is further compromised in the
anesthetized patient. Because of these cardiopulmo-
nary abnormalities, obese patients develop hypoxemia
more quickly [84]. This respiratory impairment may
persist up to 4 days after surgery [85]. Even distribu-
tion and metabolism of medications vary significantly
and often unpredictably in the obese patient [86].
Given the increased risk of perioperative morbidity
and mortality of anesthesia, morbidly obese patients
(BMI greater than 35) undergoing major surgery and
anesthesia of any type should preferentially be restrict-
ed to a hospital based surgical facility. In general, these
patients should not be considered candidates for am-
bulatory surgery. Anesthesia delivered in the office set-
ting should be restricted to patients with a BMI less
than 35.
Premedication with metaclopromide, a dopamine
receptor antagonist, increases gastric motility and low-
er esophageal sphincter tone. A histamine receptor-
blocking agent such as ranitidine used with metaclo-
promide the evening before and on the morning of sur-
gery reduces the risk of pulmonary aspiration [87].
Because of the increased risks of deep venous
thrombosis (DVT) [88] and pulmonary embolism (PE)
[89], prophylactic measures such as lower extremity
pneumatic compression devices and early ambulation
should be used.
An undetermined number of patients self-adminis-
ter herbal dietary supplements. Many of these supple-
ments contain ephedra alkaloids, which may predispo-
se the patient to perioperative hypertension and cardi-
ac arrhythmias [90]. Some herbals may result in the in-
creased incidence of bleeding from coumadin-like sub-
stances. Antiobesity medications such as aminorex fu-
marate, dexfenfluramine (Redux), fenfluramine (pon-
damin) and phentermine (Ionamin, Adipex-P, Fastin,
Oby-Cap, Obenix, Oby-trim, Zantryl) are associated
with pulmonary hypertension and valvular heart dis-
ease, even with as little as 2 months of use. While most
patients develop symptoms such as palpitations, dys-
2.2 Anesthesia in Patients with Preexisting Disease 33
pnea, chest pain, and irregular heart rate, murmur, and
edema, some patients remain asymptomatic [91].
Patients who have developed pulmonary hyperten-
sion and valvular heart disease as a result of these med-
ications are predisposed to fatal cardiac arrhythmias,
congestive heart failure, and intractable hypotension.
Some authors advocate a cardiac evaluation with echo-
cardiogram and continuous wave Doppler imaging
with color-flow examination for any patient who has
taken these antiobesity medications prior to surgery.
Sustained hypotension may not respond to ephedrine,
a popular vasopressor. Phenylephrine is the treatment
of choice for hypotension in these patients [91].
2.2.3
Hypertension
Early studies revealed a significantly increased risk of
perioperative mortality in patients with untreated hy-
pertension [92, 93]. The reduction in mortality from
cardiovascular and cerebral vascular disease resulting
from proper treatment of hypertension has been widely
accepted [94 – 96]. Although somewhat controversial,
most authors concur that preoperative stabilization of
hypertension reduces perioperative cardiovascular
complications such as ischemia [97 – 99]. Patients with
undiagnosed or poorly controlled hypertension should
be identified early in the preoperative preparation pro-
cess and referred to the family physician or internist for
evaluation and treatment.
Physicians should not mistakenly attribute severe
hypertension to the patient’s preoperative anxiety.
Because of the risk of rebound hypertension, antihy-
pertension medications should be continued up to the
morning of surgery [100], except for angiotensin-con-
verting (ACE) inhibitors, which have been associated
with hypotension during induction of general anesthe-
sia [101].
Mild to moderate perioperative hypertension may
be a response to inadequate general or local anesthesia
or pain control. In these cases, pain is usually accompa-
nied by other signs, such as the patient’s complaints, in
the case of anesthesia for the conscious patient, tachy-
cardia, and tachypnea. If hypertension persists despite
additional local anesthetic or analgesic medication,
then treatment of the blood pressure is indicated. Mod-
erate to severe blood pressure elevations occurring
during the surgery or during recovery should be treat-
ed using one or more of the antihypertensive agents
available.
Perioperative hypertension, especially if the hyper-
tension is accompanied by tachycardia, may be treated
with a beta-adrenergic blocking agent such as propran-
olol in judiciously administered, intravenous doses of
0.5 mg at 10- to 15-min intervals. Even small doses of a
beta-adrenergic blocking agent have been shown to re-
34 2 Anesthesia for Liposuction and Abdominoplasty
duce the incidence of cardiac ischemia [99]. Labetolol,
an antihpertensive agent with combined alpha-adren-
ergic and beta-adrenergic blocking properties, admin-
istered in 5 – 10 mg doses every 10 min, is also a safe
and effective alternative for treating both hypertension
and tachycardia [102].
Nifedipine (10 mg s.l.), a potent systemic and coro-
nary arteriolar dilator, effectively reduces blood pres-
sure, and may be administered in a conscious patient.
The effect of nifedipine may be additive if given with
narcotics or inhalational anesthetic agents. Because ni-
fedipine and lidocaine are both highly protein bound,
caution must be exercised when administering nifedi-
pine after high dose lidocaine tumescent anesthesia has
been administered to avoid possible toxic effects of the
lidocaine [103].
For severe hypertension, hydralazine, a potent vaso-
dilator, may be useful in 2.5 – 5 mg doses intravenously
at 10 – 15 min intervals. The effects of hydralazine may
be delayed up to 20 min and its effects prolonged. Hy-
dralazine may cause tachycardia or hypotension, espe-
cially if the patient is hypovolemic [104].
2.2.4
Diabetes Mellitus
Although patients with diabetes mellitus have a sub-
stantially increased surgical mortality rate than non-
diabetic patients [105], these complications are more
likely to be a consequence of the end-organ disease
such as cardiovascular disease, renal disease, and al-
tered wound healing [106 – 108]. While evidence sug-
gests that tight control of blood sugar in insulin-depen-
dent diabetics slows the progression of end-organ dis-
ease [109], tight control is associated with additional
risks such as hypoglycemia and even death [110].
The preoperative evaluation should identify diabetic
patients with poor control as well as medical condi-
tions associated with diabetes such as cardiovascular
disease and renal insufficiency. Diabetic patients have a
greater incidence of silent myocardial ischemia [111].
Minimum preoperative analysis includes fasting blood
sugar, glycosylated hemoglobin, electrolytes, BUN, cre-
atinine and EKG. If any doubt exists regarding the pa-
tient’s medical stability, consultation should be ob-
tained from the diabetologist, cardiologist, or nephrol-
ogist if needed. Patients with brittle diabetes or with
other coexisting medical conditions should be referred
to a hospital-based surgical unit, especially if general
anesthesia is contemplated.
The goal of perioperative management of stable type
I or type II diabetic patients is primarily to avoid hypo-
glycemia. Although patients are generally NPO after
midnight prior to surgery, a glass of clear juice may be
taken up to 2 h prior to surgery to avoid hypoglycemia.
Patients with type I diabetes should not administer in-
sulin and patients with type II diabetes should not take
the oral hypoglycemia agents on the morning of sur-
gery. Diabetic patients should be scheduled the first
case in the morning to minimize the risk of hypoglyce-
mia during the NPO period. After the patient arrives,
preoperative fasting glucose should be checked and
then an infusion of 5 % dextrose is generally initiated at
1 – 2 ml/kg/h and continued until oral fluids are tolerat-
ed in the recovery period. Usually, one-half of the pa-
tient’s scheduled dose of insulin is administered after
the intravenous dextrose is begun [112].
For surgeries longer than 2 h, at least one peripheral
blood glucose should be measured, especially if the pa-
tient is receiving general anesthesia. Blood glucose
above 200 mg/dl may be effectively managed with a
sliding scale of insulin [113]. Treatment regimens di-
rected toward tighter control of the blood sugar, such as
continuous insulin infusions, do not necessarily im-
prove the perioperative outcome [114, 115]. It is imper-
ative that, prior to discharge, patients are able to toler-
ate oral intake without nausea and vomiting. A final
glucose level should be checked prior to discharge.
2.2.5
Pulmonary Disease
Bronchial asthma, chronic bronchitis, chronic obstruc-
tive pulmonary disease, obesity, history of smoking,
and recent upper respiratory infection are the most
common medical conditions which may influence pul-
monary function in the perioperative period. An esti-
mated 4.5 % of the population may suffer some form of
reactive airway disease [116]. If these medical condi-
tions are identified in the preoperative history, a thor-
ough evaluation of the patient’s pulmonary function
should ensure. As with other medical conditions, a
careful history may help separate patients with these
medical conditions into low and high risk groups, espe-
cially since the degree of preoperative respiratory dys-
pnea closely correlates with postoperative mortality
[117]. Using a simple grading scale, the patients’ preop-
erative pulmonary function can be estimated (Ta-
ble 2.4).
Patients with level 2 dyspnea or greater should be re-
ferred to a pulmonologist for more complete evalua-
Table 2.4. Grade of dyspnea while walking. (Adapted from
Boushy et al. [117])
Level Clinical response
0 No dyspnea
1 Dyspnea with fast walking only
2 Dyspnea with one or two blocks walking
3 Dyspnea with mild exertion (walking around the
house)
4 Dyspnea at rest

tion and possibly further medical stabilization. The
benefits of elective surgery in patients with level 3 and
4 dyspnea should be carefully weighed against the in-
creased risks. Certainly, this group of patients would
not be considered good candidates for outpatient sur-
gery.
Since upper respiratory infection (URI) may alter
pulmonary function for up to 5 weeks [118], major sur-
gery requiring general endotracheal anesthesia should
be postponed, especially if the patient suffers residual
systems, such as fevers, chills, coughing and sputum
production, until the patient is completely asymptom-
atic.
While many studies confirm that patients who
smoke more than one to two packs of cigarettes daily
have a higher risk of perioperative respiratory compli-
cations than non-smokers, cessation of smoking in the
immediate preoperative period may not improve pa-
tients’ outcome. In fact, patients’ risk of perioperative
complications may actually increase if smoking is
stopped immediately prior to surgery. A full 8 weeks
may be required to successfully reduce perioperative
pulmonary risk [119].
If the physical examination of asthmatic patients re-
veals expiratory wheezing, conventional wisdom dic-
tates that potentially reversible bronchospasm should
be optimally treated prior to surgery. Therapeutic
agents include inhaled or systemic, selective beta-ad-
renergic receptor type-2 agonists (albuterol) as a sole
agent or in combination with anticholinergic (ipratro-
pium) and locally active corticosteroid (beclomethaso-
ne dipropronate) medications [120]. Continuing the
asthmatic medications up to the time of surgery [121]
and postoperative use of incentive spirometry [122] has
been shown to reduce postoperative pulmonary com-
plications.
With regard to treated stable pulmonary disease,
there are no conclusive, prospective, randomized stud-
ies to indicate which anesthesia technique or medica-
tions would improve patient outcome.
2.2.6
Obstructive Sleep Apnea
According to the National Commission on Sleep Disor-
ders Research, approximately 18 million Americans
suffer with obstructive sleep apnea (OSA). Unfortu-
nately, the majority of patients with OSA remain undi-
agnosed [123]. The incidence of sleep apnea increases
among obese patients [124]. Since the target popula-
tion for major liposuction and abdominoplasty in-
cludes patients with morbid obesity, concern about
OSA becomes more germane.
OSA is a result of a combination of excessive pha-
ryngeal adipose tissue and inadequate pharyngeal soft
tissue support [125]. During episodes of sleep apnea,
2.2 Anesthesia in Patients with Preexisting Disease 35
patients may suffer significant and sustained hypox-
emia. As a result of the pathophysiology of OSA, pa-
tients develop left and right ventricular hypertrophy
[126]. Consequently, patients have a higher risk of ven-
tricular dysarrhythmias and myocardial infarction
[127].
Most medications used during anesthesia, including
sedatives such as diazepam and midazolam, hypnotics
such as propofol, and analgesics such as fentanyl, me-
peridine and morphine, increase the risk of airway ob-
struction and respiratory depression in patients with
OSA [128]. Death may occur suddenly and silently in
patients with inadequate monitoring [129]. A combina-
tion of anatomical abnormalities make airway manage-
ment, including mask ventilation and endotracheal in-
tubation, especially challenging in obese patients with
OSA [130]. Perioperative monitoring, including visual
observation, must be especially vigilant to avoid peri-
operative respiratory arrest in patients with OSA.
For patients with severe OSA, particularly those
with additional coexisting medical conditions such as
cardiac or pulmonary disease, surgery performed on
an outpatient basis is not appropriate. For these high-
risk patients, monitoring should continue in the inten-
sive care unit until the patient no longer requires par-
enteral analgesics. If technically feasible, regional anes-
thesia may be preferable in patients with severe OSA.
Postoperatively, patients with any history of OSA
should not be discharged if they appear lethargic or
somnolent [131].
During the preoperative evaluation of the obese pa-
tient, a presumptive diagnosis of OSA may be made if
the patient has a history of loud snoring, long pauses of
breathing during sleep, as reported by the spouse, or
daytime somnolence [132]. If OSA is suspected, pa-
tients should be referred for a sleep study to evaluate
the severity of the condition.
2.2.7
Malignant Hyperthermia Susceptibility
Patients with susceptibility to malignant hyperthermia
(MH) can be successfully managed on an outpatient
basis after 4 h of postoperative monitoring [133]. Trig-
gering agents include volatile inhalation agents such as
halothane, enflurane, desflurane, isoflurane and sevof-
lurane. Even trace amounts of these agents lingering in
an anesthesia machine or breathing circuit may precip-
itate an MH crisis. Succinylcholine and chlopromazine
are other commonly used medications, which are
known triggers of MH. However, many non-triggering
medications may be safely used for local anesthesia, se-
dation-analgesia, postoperative pain control, and even
general anesthesia [134]. Nevertheless, anesthesia for
patients suspected of having MH susceptibility should
not be performed in an office-based setting. A stan-
36 2 Anesthesia for Liposuction and Abdominoplasty

dardized protocol to manage MH (available from the [139] and the possible cytochrome inhibition of con-
Malignant Hyperthermia Association of the United comitantly administered medications [140]. The maxi-
States, MHAUS) and supplies of dantrolene and cold in- mum tolerable limits of local anesthetics have been re-
travenous fluids should be available for all patients. defined with the development of the tumescent anes-
Preferably, patients with MH susceptibility should thetic technique [141]. Lidocaine doses up to 35 mg/kg
be referred to an anesthesiologist for prior consulta- were found to be safe, if administered in conjunction
tion. Intravenous dantrolene [135] and iced intrave- with dilute epinephrine during liposuction [142]. With
nous fluids are still the preferred treatment. MHAUS the tumescent technique, peak plasma levels occur
may be contacted at 800 – 98MHAUS and the MH hotli- 6 – 24 h after administration [142, 143]. More recently,
ne is 800-MH-HYPER. doses up to 55 mg/kg have been found to be within the
therapeutic safety margin [144]. However, recent guide-
lines by the American Academy of Cosmetic Surgery
2.3 recommend a maximum dose of 45 – 50 mg/kg [29].
Anesthesia for Liposuction and Abdominoplasty Since lidocaine is predominantly eliminated by he-
patic metabolism, specifically, cytochrome oxidase
Anesthesia may be divided into four broad categories: P450 34A, drugs that inhibit this microsomal enzyme
local anesthesia, local anesthesia combined with seda- may increase the potential of lidocaine toxicity [140,
tion, regional anesthesia and general anesthesia. The 145]. Table 2.6 lists some of the more common medica-
ultimate decision to select the type of anesthesia de- tions, which inhibit the cytochrome oxidase system.
pends on the type and extent of the surgery planned, Propofol and Versed, commonly used medications for
the patient’s underlying health condition and the psy- sedation and hypnosis during liposuction, are also
chological disposition of the patient. For example, a known to be cytochrome P450 inhibitors. However,
limited liposuction of less than 500 ml of fat from a since the duration of action of these drugs is only
small area in a healthy patient, with limited anxiety, 1 – 4 h, the potential inhibition should not interfere
could certainly be performed using strictly local anes- with lidocaine at the peak serum level 6 – 12 h later. Lo-
thesia without sedation. As the scope of the surgery rezepam is a sedative which does not interfere with cy-
broadens, or the patient’s anxiety level increases, the lo- tochrome oxidase and is preferred by some authors
cal anesthesia may be supplemented with oral or par- [146].
enteral analgesic or anxiolytic medication.
Table 2.6. Medications inhibiting cytochrome oxidase P450
2.3.1 3A4 (Shiffman [140])
Local Anesthesia
Amiodarone Fluoxetine Nifedipine
A variety of local anesthetics are available for infiltra- Atenolol Itraconazole Paroxetine
Carbamazepine Isoniazide Pentoxifylline
tive anesthesia. The selection of the local anesthetic de-
Cimetidine Labetolol Pindolol
pends on the duration of anesthesia required and the Clarithromycin Ketoconazole Propofol
volume of anesthetic needed. Chloramphenicol Methadone Propranolol
The traditionally accepted, pharmacological pro- Cyclosporin Methyprednisolone Quinidine
files of common anesthetics used for infiltrative anes- Danazol Metoprolol Sertraline
Dexamethasone Miconazole Tetracyline
thesia for adults are summarized in Table 2.5. The max- Diltiazam Midazolam Terfenidine
imum doses may vary widely depending on the type of Erythromycin Nadolol Thyroxine
tissue injected [136], the rate of administration [137], Fluconazole Nefazodone Timolol
the age, underlying health, and body habitus of the pa- Flurazepam Nicardipine Triazolam
Verapamil
tient [138], the degree of competitive protein binding

Table 2.5. Clinical pharmacology of common local anesthetics for infiltrative anesthesia. (Adapted from Covino and Wildsmith
[61])
Agent Concen- Without epinephrine With epinephrine
tration ( %) Duration of action (min) Maximum Duration of action (min) Maximum
mg/kg total mg total ml dose mg/kg total mg/kg total ml dose
Lidocaine 1.0 30 – 60 4 300 30 120 7 500 50
Mepivacaine 1.0 45 – 90 4 300 30 120 7 500 50
Etidocaine 0.5 120 – 180 4 300 60 180 5.5 400 80
Bupivacaine 0.25 120 – 240 2.5 185 75 180 3 225 90
Ropivacaine 0.2 120 – 360 2.7 200 8 120 – 360 2.7 200 80

Certainly, significant toxicity has been associated
with high doses of lidocaine as a result of tumescent an-
esthesia during liposuction [146]. The systemic toxicity
of local anesthetic has been directly related to the se-
rum concentration by many authors [139, 142 – 144,
146 – 148]. Early signs of toxicity, usually occurring at
serum levels of about 3 – 4 µg/ml for lidocaine, include
circumoral numbness and lightheadedness, and tinni-
tus. As the serum concentration increases toward 8 µg/
ml, tachycardia, tachypnea, confusion, disorientation,
visual disturbance, muscular twitching and cardiac de-
pression may occur. At still higher serum levels above
8 µg/ml, unconsciousness and seizures may ensue.
Complete cardiorespiratory arrest may occur between
10 and 20 µg/ml [139, 146, 147]. However, the toxicity of
lidocaine may not always correlate exactly with the
plasma level of lidocaine presumably because of the
variable extent of protein binding in each patient and
the presence of active metabolites [139] and other fac-
tors already discussed including the age, ethnicity,
health, and body habitus of the patient, and additional
medications.
Ropivacaine, a long lasting local anesthetic, has less
cardiovascular toxicity than bupivacaine and may be a
safer alternative to bupivacaine if a local anesthetic of
longer duration is required [149, 150]. The cardiovas-
cular toxicity of bupivacaine and etidocaine is much
greater than that of lidocaine [149 – 151]. While bupiva-
caine toxicity has been associated with sustained ven-
tricular tachycardia and sudden profound cardiovascu-
lar collapse [152, 153], the incidence of ventricular
dysarrhythmias has not been as widely acknowledged
with lidocaine or mepivacaine toxicity. In fact, ventric-
ular tachycardia of fibrillation was not observed despite
the use of supraconvulsant doses of intravenous doses
of lidocaine, etidocaine, or mepivacaine in the animal
model [150].
Indeed, during administration of infiltrative lido-
caine anesthesia, rapid anesthetic injection into a high-
ly vascular area or accidental intravascular injection
leading to sudden toxic levels of anesthetics resulting in
sudden onset of seizures or even cardiac arrest or car-
diovascular collapse has been documented [154, 155].
One particularly disconcerting case presented by
Christie confirms the fatal consequence of a lidocaine
injection of 200 mg in a healthy patient [156]. Seizure
and death occurred following a relatively low dose of li-
docaine and a serum level of only 0.4 mg/100 ml or
4 µg/ml. A second patient suffered cardiac arrest with a
blood level of 0.58 mg/100 ml or 5 µg/ml [156]. Al-
though continued postmortem metabolism may artifi-
cially reduce serum lidocaine levels, the reported se-
rum levels associated with mortality in these patients
were well below the 8 – 20 µg/ml considered necessary
to cause seizures, myocardial depression, and cardiore-
spiratory arrest. The 4 µg/ml level reported by Christie
2.3 Anesthesia for Liposuction and Abdominoplasty 37
[156] is uncomfortably close to the maximum serum
levels reported by Ostad et al. [140] of 3.4 and 3.6 µg/ml
following tumescent lidocaine doses of 51.3 and
76.7 mg/kg respectively. Similar near toxic levels were
reported in individual patients receiving about 35 mg/
kg of lidocaine by Samdal et al. [157]. Pitman [158] re-
ported that toxic manifestations occurred 8 h postoper-
atively after a total dose of 48.8 mg/kg which resulted
from a 12-h plasma lidocaine level of 3.7 µg/kg. Ostad et
al. [140] concludes that because of the poor correlation
of lidocaine doses with the plasma lidocaine levels, an
extrapolation of the maximum safe dose of lidocaine
for liposuction cannot be determined. Given the devas-
tating consequences of lidocaine toxicity, physicians
must exercise extreme caution while attempting to
push the acceptable safe limits to ever-higher levels of
tumescent anesthesia. Physicians must consider the
important variables affecting susceptibility of individ-
ual patients to lidocaine toxicity before “boldly going
where no surgeon has gone before”, especially since
plasma lidocaine levels typically peak after the patient
is at home.
Patients who report previous allergies to anesthetics
may present a challenge to surgeons performing lipo-
suction. Although local anesthetics of the aminoester
class such as procaine are associated with allergic reac-
tions, true allergic phenomena to local anesthetics of
the aminoamide class, such as lidocaine, are extremely
rare [158, 159]. Allergic reactions may occur to the pre-
servative in the multidose vials. Tachycardia and gener-
alized flushing may occur with rapid absorption of the
epinephrine contained in some standard local anes-
thetic preparations. The development of vasovagal re-
actions after injections of any kind may cause hypoten-
sion, bradycardia, diaphoresis, pallor, nausea, and loss
of consciousness. These adverse reactions may be mis-
interpreted by the patient and even the physician as al-
lergic reactions [159]. A careful history from the pa-
tient describing the apparent reaction usually clarifies
the cause. If there is still concern about the possibility
of true allergy to local anesthetic, then the patient
should be referred to an allergist for skin testing.
In the event of a seizure following a toxic dose of lo-
cal anesthetic, proper airway management and main-
taining oxygenation is critical. Seizure activity may be
aborted with intravenous diazepam (10 – 20 mg), mida-
zolam (5 – 10 mg), or thiopental (100 – 200 mg).
Although the ventricular arrhythmias associated
with bupivacaine toxicity are notoriously intractable
[152, 153], treatment is still possible using large doses
of atropine, epinephrine and bretylium [161, 162].
Some studies indicate that lidocaine should not be used
[163]. Pain associated with local anesthetic administra-
tion is due to the pH of the solution and may be reduced
by the addition of 1 mEq of sodium bicarbonate to
10 ml of anesthetic [164].
38 2 Anesthesia for Liposuction and Abdominoplasty
EMLA (eutectic mixture of local anesthetics), a com-
bination of lidocaine and prilocaine, may provide ef-
fective topical anesthesia over smaller areas such as the
face. However, an occlusive dressing must be applied,
and at least 60 min is required for adequate anesthesia
[165]. Except for small, localized surgical procedures,
topical anesthetics do not have a wide application for li-
posuction or abdominoplasty.
2.3.2
Sedative-Analgesic Medication (SAM)
Most liposuctions are performed with a combination of
local tumescent anesthesia and supplemental sedative-
analgesic medications (SAM) administered orally
(p.o.), intramuscularly (i.m.), or intravenously (i.v.).
Abdominoplasties performed under local or regional
anesthesia generally require SAM. The goals of admin-
istering supplemental medications are to reduce anxi-
ety (anxiolysis), the level of consciousness (sedation),
unanticipated pain (analgesia), and, in some cases, to
eliminate recall of the surgery (amnesia).
Sedation may be defined as the reduction of the level
of consciousness usually resulting from pharmacologi-
cal intervention. The level of sedation may be further
divided into three broad categories, conscious seda-
tion, deep sedation, and general anesthesia. The term
conscious sedation has evolved to distinguish a lighter
state of anesthesia with a higher level of mental func-
tioning whereby the life-preserving protective reflexes
are independently and continuously maintained. Fur-
thermore, the patient is able to respond appropriately
to physical and verbal stimulation [166].
Life preserving protective reflexes (LPPRs) may be
defined as the involuntary physical and physiological
responses that maintain the patient’s life which, if inter-
rupted, result in inevitable and catastrophic physiolog-
ical consequences. The most obvious examples of
LPPRs are the ability to maintain an open airway, swal-
lowing, coughing, gagging, and spontaneous breath-
ing. Some involuntary physical movements such as
head turning or attempts to assume an erect posture
may be considered LPPRs if these reflex actions occur
in an attempt to improve airway patency such as expel-
ling oropharyngeal contents. The myriad of homeo-
static mechanisms to maintain blood pressure, heart
function and body temperature may even be consid-
ered LPPRs.
As the level of consciousness is further depressed to
the point that the patient is not able to respond pur-
posefully to verbal commands or physical stimulation,
the patient enters into a state referred to as deep seda-
tion. In this state, there is a significant probability of
loss of LPPRs. Ultimately, as total loss of consciousness
occurs and the patient no longer responds to verbal
command or painful stimuli, the patient enters a state
of general anesthesia [166]. During general anesthesia
the patient most likely loses the LPPRs.
In actual practice, the delineation between the levels
of sedation becomes challenging at best. The loss of
consciousness occurs as a continuum. With each incre-
mental change in the level of consciousness, the likeli-
hood of loss of LPPRs increases. Since the definition of
conscious sedation is vague, current ASA guidelines
consider the term sedation-analgesia a more relevant
term than conscious sedation [25]. The term sedative-
analgesic medication (SAM) has been adopted by some
facilities. Monitored anesthesia care (MAC) has been
generally defined as the medical management of pa-
tients receiving local anesthesia during surgery with or
without the use of supplemental medications. MAC
usually refers to services provided by the anesthesiolo-
gist or the Certified Registered Nurse Anesthetist
(CRNA). The term “local standby” is no longer used
because it mischaracterizes the purpose and activity of
the anesthesiologist or CRNA.
Surgical procedures performed using a combination
of local anesthetic and SAM usually have a shorter re-
covery time than similar procedures performed under
regional or general anesthesia [167]. Using local anes-
thesia alone, without the benefit of supplemental medi-
cation is associated with a greater risk of cardiovascu-
lar and hemodynamic perturbations such as tachycar-
dia, arrhythmias, and hypertension particularly in pa-
tients with preexisting cardiac disease or hypertension
[168]. Patients usually prefer sedation while undergo-
ing surgery with local anesthetics [169]. While the ad-
dition of sedatives and analgesics during surgery using
local anesthesia seems to have some advantages, use of
SAM during local anesthesia is certainly not free of
risk. A study by the Federated Ambulatory Surgical As-
sociation concluded that local anesthesia, with supple-
mental medications, was associated with more than
twice the number of complications than with local an-
esthesia alone. Furthermore, local anesthesia with
SAM was associated with greater risks than general an-
esthesia [60]. Significant respiratory depression as de-
termined by the development of hypoxemia, hypercar-
bia, and respiratory acidosis often occurs in patients af-
ter receiving minimal doses of medications. This respi-
ratory depression persists even in the recovery period
[170, 171].
One explanation for the frequency of these compli-
cations is the wide variability of patients’ responses to
these medications. Up to 20-fold differences in the dose
requirements for some medications such as diazepam,
and up to 5-fold variations for some narcotics such as
fentanyl, have been documented in some patients [172,
173]. Even small doses of fentanyl as low as 2 µg/kg,
considered by many physicians as subclinical, produce
respiratory depression for more than 1 h in some pa-
tients [174]. Combinations of even small doses of seda-

tives, such as midazolam, and narcotics, such as fenta-
nyl, may act synergistically (effects greater than an ad-
ditive effect) in producing adverse side effects such as
respiratory depression and hemodynamic instability
[175]. The clearance of many medications may vary de-
pending on the amount and duration of administra-
tion, a phenomenon known as context-sensitive half-
life. The net result is increased sensitivity and duration
of action to medication for longer surgical cases [176].
Because of these variations and interactions, predicting
any given patient’s dose response is a daunting task. Pa-
tients appearing awake and responsive may, in an in-
stant, slip into unintended levels of deep sedation with
greater potential of loss of LPPRs. Careful titration of
these medications to the desired effect combined with
vigilant monitoring are the critical elements in avoid-
ing complications associated with the use of SAM.
Supplemental medication may be administered via
multiple routes including oral, nasal, transmucosal,
transcutaneous, intravenous, intramuscular and rectal.
While intermittent bolus has been the traditional
method to administer medication, continuous infusion
and patient controlled delivery result in comparable
safety and patient satisfaction [177, 178].
Benzodiazepines such as diazepam, midazolam and
lorezepam remain popular for sedation and anxiolysis.
Patients and physicians especially appreciate the potent
amnestic effects of this class of medications, especially
midazolam. The disadvantages of diazepam include the
higher incidence of pain on intravenous administra-
tion, the possibility of phlebitis [179], and the pro-
longed half-life of up to 20 – 50 h. Moreover, diazepam
has active metabolites which may prolong the effects of
the medication even into the postoperative recovery
time [180]. Midazolam, however, is more rapidly me-
tabolized, allowing for a quicker and more complete re-
covery for outpatient surgery [180]. Because the seda-
tive, anxiolytic and amnestic effects of midazolam are
more profound than other benzodiazepines and the re-
covery is more rapid, patient acceptance is usually
higher [181]. Since lorezepam is less affected by medi-
cations altering cytochrome P459 metabolism [182], it
has been recommended as the sedative of choice of li-
posuctions which require a large dose lidocaine tumes-
cent anesthesia [146]. The disadvantage of lorezepam is
the slower onset of action and the 11 – 22 h elimination
half-life, making titration cumbersome and postopera-
tive recovery prolonged [180].
Generally, physicians who use SAM titrate a combi-
nation of medications from different classes to tailor
the medications to the desired level of sedation and an-
algesia for each patient. Use of pre-packaged combina-
tions of medications defeats the purpose of the selec-
tive control of each medication. Typically, sedatives
such as the benzodiazepines are combined with narcot-
ic analgesics such as fentanyl, meperidine, or morphine
2.3 Anesthesia for Liposuction and Abdominoplasty 39
during local anesthesia to decrease pain associated
with local anesthetic injection or unanticipated break-
through pain. Fentanyl has the advantage of rapid onset
and duration of action of less than 60 min. However,
because of synergistic action with sedative agents, even
doses of 25 – 50 µg can result in respiratory depression
[183]. Other medications with sedative and hypnotic
effects such as a barbiturate, ketamine, or propofol are
often added. Adjunctive analgesics such as ketorolac
may be administered for addition of analgesic activity.
As long as the patient is carefully monitored, several
medications may be titrated together to achieve the ef-
fects required for the patient characteristics and the
complexity of the surgery. Fixed combinations of medi-
cations are not advised [25].
More potent narcotic analgesics with rapid onset of
action and even shorter duration of action than fenta-
nyl include sufenanil, alfenanil, and remifenanil and
may be administered using intermittent boluses or con-
tinuous infusion in combination with other sedative or
hypnotic agents. However, extreme caution and scru-
pulous monitoring is required when these potent nar-
cotics are used because of the risk of respiratory arrest
[184, 185]. Use of these medications should be restrict-
ed to the anesthesiologist or the CRNA. A major disad-
vantage of narcotic medication is the perioperative
nausea and vomiting [186].
Many surgeons feel comfortable administering SAM
to patients. Others prefer to use the services of an anes-
thesiologist or CNRA. Prudence dictates that for pro-
longed or complicated surgeries or for patients with
significant risk factors, the participation of the anes-
thesiologist or CRNA during MAC anesthesia is prefer-
able. Regardless of who administers the anesthetic
medications, the monitoring must have the same level
of vigilance.
Propofol, a member of the alkylphenol family, has
demonstrated its versatility as a supplemental sedative-
hypnotic agent for local anesthesia and of regional an-
esthesia. Propofol may be used alone or in combination
with a variety of other medications. Rapid metabolism
and clearance results in faster and more complete re-
covery with less postoperative hangover than other
sedative-hypnotic medications such as midazolam and
methohexital [187, 188]. The documented antiemetic
properties of propofol yield added benefits of this med-
ication [189]. The disadvantages of propofol include
pain on intravenous injection and the lack of amnestic
effect [190]. However, the addition of 3 ml of 2 % lido-
caine to 20 ml of propofol virtually eliminates the pain
on injection with no added risk. If an amnestic re-
sponse is desired, a small dose of a benzodiazepine,
such as midazolam (5 mg i.v.), given in combination
with propofol, provides the adequate amnesia. Rapid
administration of propofol may be associated with sig-
nificant hypotension, decreased cardiac output [191],
40 2 Anesthesia for Liposuction and Abdominoplasty

and respiratory depression [192]. Continuous infusion
with propofol results in a more rapid recovery than
similar infusions with midazolam [193]. Patient-con-
trolled sedation with propofol has also been shown to
be safe and effective [194].
Barbiturate sedative-hypnotic agents such as thio-
pental and methohexital, while older, still play a role in
many clinical settings. In particular, methohexital,
with controlled boluses (10 – 20 mg i.v.) or limited infu-
sions remain a safe and effective sedative-hypnotic al-
ternative with rapid recovery. However, with prolonged
administration, recovery from methohexital may be
delayed compared to propofol [195].
Ketamine, a phencyclidine derivative, is a unique
agent because of its combined sedative and analgesic
effects and the absence of cardiovascular depression in
healthy patients [196]. Because the CNS effects of keta-
mine results in a state similar to catatonia, the resulting
anesthesia is often described as dissociative anesthesia.
Although gag and cough reflexes are more predictably
maintained with ketamine, emesis and pulmonary as-
piration of gastric contents is still possible [197]. Un-
fortunately, a significant number of patients suffer dis-
tressing postoperative psychomimetic reactions [198].
While concomitant administration of benzodiazepines
attenuates these reactions, the postoperative psycho-
logical sequelae limit the usefulness of ketamine for
most elective outpatient surgeries.
Droperidol, a butyrophenone and a derivative of
haloperidol, acts as a sedative, hypnotic, and antiemet-
ic medication. Rather than causing global CNS depres-
sion like barbiturates, droperidol causes more specific
CNS changes similar to phenothiazines. For this rea-
son, the cataleptic state caused by droperidol is referred
to as neuroleptic anesthesia [199]. Droperidol has been
used effectively in combination with various narcotic
medications. Innovar is a combination of droperidol
and fentanyl. While droperidol has a minimal effect on
respiratory function if used as a single agent, when
combined with narcotic medication, a predictable
dose-dependent respiratory depression may be antici-
pated [200]. Psychomimetic reactions such as dyspho-
ria or hallucinations are frequent, unpleasant side ef-
fects of droperidol. Benzodiazepines or narcotics re-
duce the incidence of these unpleasant side effects
[201]. Extrapyramidal reactions such as dyskinesias,
torticollis, or oculogyric spasms may also occur, even
with small doses of droperidol. Dimenhydrinate usual-
ly reverses these complications [202]. Hypotension
may occur as a consequence of droperidol’s alpha-ad-
renergic blocking characteristics. One rare complica-
tion of droperidol is the neurolept malignant syndrome
(NMS) [203], a condition very similar to malignant hy-
perthermia, characterized by extreme temperature ele-
vations and rhabdomyolysis. The treatment of NMS
and malignant hyperthermia is essentially the same.
While droperidol has been used for years without ap-
preciable myocardial depression [201], a surprising an-
nouncement from the Federal Drug Administration
warned of sudden cardiac death resulting after the ad-
ministration of standard, clinically useful doses [204].
Unfortunately, this potential complication makes the
routine use of this once very useful medication difficult
to justify given the presence of other alternative medi-
cations.
Butorphanol, buprenorphine, and nalbuphine are
three synthetically derived opiates, which share the
properties of being mixed agonist-antagonist at the
opiate receptors. These medications are sometimes
preferred as supplemental analgesics during local, re-

Medication Bolus dose Average adult dose Continuous infusion Table 2.7. Common medica-
rate (µg/kg/min) tions and dosages used for
sedative analgesia. These
Narcotic analgesics doses may vary depending
Alfentanil 5 – 7 µg/kg 30 – 50 µg 0.2 – 0.5 on age, gender, underlying
Fentanyl 0.3 – 0.7 µg/kg 25 – 50 µg 0.01 health status, and other con-
Meperidine 0.2 mg 10 – 20 mg i.v., 50 – 100 mg i.m. NA comitantly administered
Morphine 0.02 mg 1 – 2 mg i.v., 5 – 10 mg i.m. NA medications. (Adapted from
Remifentanil 0.5 – 1.0 µg/kg 10 – 25 µg 0.025 – 0.05 Philip [214], SaRego et al.
Sufentanil 0.1 – 0.2 µg/kg 10 µg 0.001 – 0.002 [215], and Fragen [216])
Opiate agonist-antagonist analgesics
Buprenorphene 4 – 6 µg/kg 0.3 mg NA
Butorphanol 2 – 7 µg/kg 0.1 – 0.2 mg NA
Nalbuphine 0.03 – 0.1 mg/kg 10 mg NA
Sedative hypnotics
Diazepam 0.05 – 0.1 mg/kg 5 – 7.5 mg NA
Methohexital 0.2 – 0.5 mg/kg 10 – 20 mg 10 – 50
Midazolam 30 – 75 µg/kg 2.5 – 5.0 0.25 – 0.5
Propofol 0.2 – 0.5 mg/kg 10 – 20 mg 10 – 50
Thiopental 0.5 – 1.0 mg/kg 25 – 50 mg 50 – 100
Dissociative anesthetics
Ketamine 0.2 – 0.5 mg/kg 10 – 20 mg 10

gional, or general anesthesia, because they partially re-
verse the analgesic and respiratory depressant effects
of other narcotics. While these medications result in
respiratory depression at lower doses, a ceiling effect
occurs at a higher dose, thereby limiting the respirato-
ry depression. Still, respiratory arrest is possible, espe-
cially if these medications are combined with other
medications with respiratory depressant properties
[205]. While the duration of action of butorphanol is
2 – 3 h, nalbuphine has a duration of action of about
3 – 6 h and buprenorphan up to 10 h, making these
medications less suitable for surgeries of shorter dura-
tion. Table 2.7 summarizes the recommended doses
for SAM.
2.3.3
General Anesthesia
While some authors attribute the majority of complica-
tions occurring during and after liposuction to the ad-
ministration of systemic anesthesia [148, 206], others
consider sedation and general anesthesia safe and ap-
propriate alternatives in indicated cases [19, 158, 207,
208]. In fact, Klein correctly acknowledges that most of
the complications attributed to midazolam and narcot-
ic combinations occurred as a result of inadequate
monitoring [148]. Although significant advances have
been made in the administration of local anesthetics
and supplemental medications, the use of general anes-
thesia may still be the anesthesia technique of choice
for many patients. General anesthesia is especially ap-
propriate when working with patients suffering ex-
treme anxiety, high tolerance to narcotic or sedative
medications, or if the surgery is particularly complex.
The goals of a general anesthetic are a smooth induc-
tion, a prompt recovery, and minimal side effects, such
as nausea, vomiting, or sore throat. The inhalation an-
esthetic agents, halothane, isoflurane, and enflurane,
remain widely popular because of the safety, reliability,
and convenience of use. The newer inhalation agents,
sevoflurane and desflurane, share the added benefit of
prompt emergence [209, 210]. Nitrous oxide, a long-
time favorite anesthetic inhalation agent, may be asso-
ciated with postoperative nausea and vomiting [211].
Patients receiving nitrous oxide also have a greater risk
of perioperative hypoxemia.
The development of potent, short-acting sedative
opiates, analgesics, and muscle relaxant medications
has resulted in a newer medication regimen that per-
mits the use of intravenous agents exclusively. The
same medications that have been discussed for SAM
can also be used during general anesthesia as sole
agents or in combination with the inhalation agents
[212]. The anesthesiologist or CRNA should preferen-
tially be responsible for the administration and moni-
toring of a general anesthesia.
2.3 Anesthesia for Liposuction and Abdominoplasty 41
Airway control is a key element in the management
of the patient under general anesthesia. Maintaining a
patent airway, ensuring adequate ventilation, and pre-
vention of aspiration of gastric contents are the goals
of successful airway management. For shorter cases,
the airway may be supported by an oropharyngeal air-
way and gas mixtures delivered by an occlusive mask.
For longer or more complex cases, or if additional fa-
cial surgery is planned requiring surgical field avoid-
ance, then the airway may be secured using laryngeal
mask anesthesia (LMA) or endotracheal intubation
[213].
2.3.4
Preoperative Preparation
Generally, medications, which may have been required
to stabilize the patient’s medical conditions, should be
continued up to the time of surgery. Notable exceptions
include anticoagulant medications, monoamine oxi-
dase inhibitors (MAO) [217, 218], and possibly the an-
giotensin converting enzyme (ACE) inhibitor medica-
tions [219, 220]. It is generally accepted that MAO in-
hibitors, carboxazid (Marplan), deprenyl (Eldepryl),
pargyline (Eutonyl), phenelzine (Nardil), tranylcypro-
mine (Parnate), be discontinued 2 – 3 weeks prior to
surgery, especially for elective cases, because of the in-
teractions with narcotic medication, specifically hyper-
pyrexia, and certain vasopressor agents, specifically
ephedrine [217, 218]. Patients taking ACE inhibitors
(captopril, enalapril, and lisinopril) may have a greater
risk for hypotension during general anesthesia [220].
As previously discussed, diabetics may require a reduc-
tion in dosage of their medication. However, if the risks
of discontinuing any of these medications outweigh the
benefits of the proposed elective surgery, the patient
and physician may decide to postpone, modify, or can-
cel the proposed surgery.
Previous requirements of complete preoperative fast-
ing for 10 – 16 h are considered unnecessary by many an-
esthesiologists [221, 222]. More recent investigations
have demonstrated that gastric volume may be less 2 h
after oral intake of 8 ounces of clear liquid than after
more prolonged fasting [223]. Furthermore, prolonged
fasting may increase the risk of hypoglycemia [224].
Many patients appreciate an 8 ounce feeding of their fa-
vorite caffeinated elixir 2 h prior to surgery. Preopera-
tive sedative medications may also be taken with a small
amount of water or juice. Abstinence from solid food in-
gestion for 10 – 12 h prior to surgery is still recommend-
ed. Liquids taken prior to surgery must be clear [225],
e.g., coffee without cream or juice without pulp.
Healthy outpatients are no longer considered higher
risk for gastric acid aspiration, and therefore routine
use of antacids, histamine type-2 (H2) antagonists, or
gastrokinetic medications is not indicated. However,
42 2 Anesthesia for Liposuction and Abdominoplasty
patients with marked obesity, hiatal hernia, or diabetes
mellitus have higher risks for aspiration. These patients
may benefit from selected prophylactic treatment
[226]. Sodium citrate, an orally administered, non-par-
ticulate antacid, rapidly increases gastric pH. However,
its unpleasant taste and short duration of action limits
its usefulness in elective surgery [227]. Gastric volume
and pH may be effectively reduced by H2 receptor an-
tagonists. Cimetidine (300 mg p.o., 1 – 2 h prior to sur-
gery) reduces gastric volume and pH. However, cimeti-
dine is also a potent cytochrome oxidase inhibitor and
may increase the risk of reactions to lidocaine during
tumescent anesthesia [228]. Ranitidine (150 – 300 mg
90 – 120 min prior to surgery) [229] or famotidine
(20 mg p.o. 60 min prior to surgery) are equally effec-
tive but have a better safety profile than cimetidine
[230].
Omeprazole, which decreases gastric acid secre-
tion by inhibiting the proton pump mechanism of the
gastric mucosa, may prove to be a safe and effective al-
ternative to the H2 receptor antagonists [230]. Metac-
lopramide (10 – 20 mg p.o. or i.v.), a gastrokinetic
agent, which increases gastric motility and lower
esophageal sphincter tone, may be effective in patients
with reduced gastric motility, such as diabetics or pa-
tients receiving opiates. However, extrapyramidal side
effects limit the routine use of the medication [231,
232].
Postoperative nausea and vomiting (PONV) re-
mains one of the more vexing complications of anes-
thesia and surgery [233]. In fact, patients dread PONV
more than any other complication, even postoperative
pain [234]. PONV is the most common postoperative
complication [235, 236] and the common cause of post-
operative patient dissatisfaction [237]. Use of prophy-
lactic antiemetic medication has been shown to reduce
the incidence of PONV [238]. Even though many pa-
tients do not suffer PONV in the recovery period after
ambulatory anesthesia, more than 35 % of patients de-
velop PONV after discharge [239].
Droperidol, 0.625 – 1.25 mg i.v., is an extremely cost-
effective antiemetic [240]. However, troublesome side
effects such as sedation, dysphoria, extrapyramidal re-
actions [241], and more recently cardiac arrest have
been described [203]. These complications may pre-
clude the widespread use of droperidol altogether. On-
dansetron, a seratonin antagonist (4 – 8 mg i.v.), is one
of the most effective antiemetic medications available
without sedative, dysphoric or extrapyramidal sequel-
ae [242, 243]. The antiemetic effects of ondansetron
may reduce PONV for up to 24 h postoperatively [244].
The effects of ondansetron may be augmented by the
addition of dexamethasone (4 – 8 mg) [245] or droperi-
dol (1.25 mg i.v.) [246]. Despite its efficacy, cost re-
mains a prohibitive factor in the routine prophylactic
use of ondansetron, especially in the office setting. On-
dansetron is available in a parenteral preparation and
as orally disintegrating tablets and oral solution.
Promethazine (12.5 – 25 mg p.o., p.r., or i.m.) and
chlorpromazine (5 – 10 mg p.o., or i.m. and 25 mg p.r.)
are two older phenothiazines which are still used by
many physicians as prophylaxis, especially in combina-
tion with narcotic analgesics. Once again, sedation and
extrapyramidal effects may complicate the routine pro-
phylactic use of these medications [232].
Preoperative atropine (0.4 mg i.m.), glycopyrrolate,
(0.2 mg i.m.), and scopolamine (0.2 mg i.m.), anticholin-
ergic agents once considered standard preoperative
medication because of their vagolytic and antisialogic
effects, are no longer popular because of side effects
such as dry mouth, dizziness, tachycardia, and disorien-
tation [247]. Transdermal scopolamine, applied 90 min
prior to surgery, effectively reduces PONV. However, the
incidence of dry mouth and drowsiness is high [248],
and toxic psychosis is a rare complication [249]. Antihis-
tamines, such as dimenhydrinate (25 – 50 mg p.o., i.m.,
or i.v.) and hydroxyzine (50 mg p.o. or i.m.), may also be
used to treat and prevent PONV with few side effects ex-
cept for possible postoperative sedation [250].
The selection of anesthetic agents may also play a
major role in PONV. The direct antiemetic actions of
propofol have been clearly demonstrated [251]. Anes-
thetic regimens utilizing propofol, alone or in combi-
nation with other medications, are associated with sig-
nificantly less PONV [252]. Although still controver-
sial, nitrous oxide is considered by many authors a
prime suspect among possible causes of PONV [211,
253, 254]. Use of opiates is also considered a culprit in
the development of PONV and the delay of discharge
after outpatient surgery [186, 255 – 257]. Adequate fluid
hydration has been shown to reduce PONV [258].
One goal of preoperative preparation is to reduce
patients’ anxiety. Many simple, non-pharmacological
techniques may be extremely effective in reassuring
both patients and families, starting with a relaxed,
friendly atmosphere and a professional, caring, and at-
tentive office staff. With proper preoperative prepara-
tion, pharmacological interventions may not even be
necessary. However, a variety of oral and parenteral an-
xiolytic-sedative medications are frequently called up-
on to provide a smooth transition to the operative
room. Diazepam (5 – 10 mg p.o.), given 1 – 2 h preoper-
atively, is a very effective medication, which usually
does not prolong recovery time [259]. Parenteral diaze-
pam (5 – 10 mg i.v. or i.m.) may also be given immedi-
ately preoperatively. However, because of a long elimi-
nation half-life of 24 – 48 h, and active metabolites with
an elimination half-life of 50 – 120 h, caution must be
exercised when using diazepam, especially in shorter
cases, so that recovery is not delayed [260]. Pain and
phlebitis with i.v. or i.m. administration reduces the
popularity of diazepam [179].

Lorezepam (1 – 2 mg p.o. or s.l., 1 – 2 h preoperative-
ly) is also an effective choice for sedation or anxiolysis.
However, the prolonged duration of action may pro-
long recovery time after shorter cases [261]. Midazo-
lam (5 – 7.5 mg i.m., 30 min preoperatively, or 2 mg i.v.
minutes prior to surgery) is a more potent anxiolytic-
sedative medication with more rapid onset and shorter
elimination half-life, compared to diazepam [262]. Un-
fortunately, oral midazolam has unpredictable results
and is not considered a useful alternative for preopera-
tive medication [263]. Oral narcotics, such as oxycodo-
ne (5 – 10 mg p.o.), may help relieve the patient’s intra-
operative breakthrough pain during cases involving
more limited liposuction with minimal potential peri-
operative sequelae. Parenteral opioids, such as mor-
phine (5 – 10 mg i.m., or 1 – 2 mg i.v.), demerol
(50 – 100 mg i.m., or 10 – 20 mg i.v.), fentanyl (10 – 20 µg
i.v.), or sufentanil (1 to 2 ug i.v.), may produce sedation
and euphoria and may decrease the requirements for
other sedative medication. The level of anxiolysis and
sedation is still greater with the benzodiazepines than
with the opioids. Premedication with narcotics has
been shown to have minimal effects on postoperative
recovery time. However, opioid premedication may in-
crease PONV [264, 265].
Antihistamine medications, such as hydroxyzine
(50 – 100 mg i.m, or 50 – 100 mg p.o.), dimenhydrinate
(50 mg p.o., i.m., or 25 mg i.v.), are still used safely in
combination with other premedications, especially the
opioids, to add sedation and to reduce nausea and pru-
ritis. However, the anxiolytic and amnestic effects are
not as potent as the benzodiazepines [266]. Barbitu-
rates, such as secobarbital and pentobarbital, once a
standard premedication have largely been replaced by
the benzodiazepines.
Postoperative PE is an unpredictable and devastat-
ing complication with an estimated incidence of
0.1 – 5 %, depending on the type of surgical case [267],
and a mortality rate of about 15 % [267]. Risk factors
for thromboembolism include prior history or family
history of DVT or PE, obesity, smoking, hypertension,
use of oral contraceptives and hormone replacement
therapy, and patients over 60 years of age [268]. Esti-
mates for the incidence of postoperative DVT vary be-
tween 0.8 % for outpatients undergoing herniorrha-
phies [269], to up to 80 % for patients undergoing total
hip replacement [267]. Estimates of fatal PE also vary
from 0.1 % for patients undergoing general surgeries to
up to 1 – 5 % of patients undergoing major joint replace-
ment [267]. While a recent national survey of physi-
cians performing tumescent liposuction, in a total of
15,336 patients, indicated that no patient suffered DVT
or PE [270], only 66 physicians who perform liposuc-
tion responded out of 1,778 questionnaires sent, which
is a mere 3.7 % response rate. A review of 26,591 abdo-
minoplasties revealed 9 cases of fatal PE, or 0.03 %, but
2.3 Anesthesia for Liposuction and Abdominoplasty 43
gave no information regarding the incidence of non-fa-
tal PE [271]. Other reports suggest that the incidence of
pulmonary embolism after tumescent liposuction and
abdominoplasty may be more common than reported
[272 – 275]. One study revealed that unsuspected PE
may actually occur in up to 40 % of patients who devel-
op DVT [276].
Prevention of DVT and PE should be considered an
essential component of the perioperative management.
Although unfractionated heparin reduces the rate of fa-
tal PE [277], many surgeons are reluctant to use this
prophylaxis because of concerns of perioperative hem-
orrhage. The low molecular weight heparins, enoxapa-
rin, dalteparin, ardeparin, and danaparoid, a heparino-
id, are available for prophylactic indications. Graduated
compression stockings and intermittent pneumatic
lower extremity compression devices applied through-
out the perioperative period, until the patient has be-
come ambulatory, are considered very effective and safe
alternatives in the prevention of postoperative DVT and
PE [278, 279]. Even with prophylactic therapy, PE may
still occur up to 30 days after surgery [280]. Physicians
should be suspicious of PE if patients present postoper-
atively with dyspnea, chest pain, cough, hemoptysis,
pleuritic pain, dizziness, syncope, tachycardia, cyano-
sis, shortness of breath, or wheezing [268].
2.3.5
Perioperative Monitoring
The adoption of a standardized perioperative monitor-
ing protocol has resulted in a quantum leap in periop-
erative patient safety. The standards for basic perioper-
ative monitoring were approved by the ASA in 1986 and
amended in 1995 [17]. These monitoring standards are
now considered applicable to all types of anesthetics,
including local with or without sedation, regional, or
general anesthesia, regardless of the duration or com-
plexity of the surgical procedure and regardless of
whether the surgeon or anesthesiologist is responsible
for the anesthesia. Vigilant and continuous monitoring
and compulsive documentation facilitates early recog-
nition of deleterious physiological events and trends,
which, if not recognized promptly, could lead to irre-
versible pathological spirals, ultimately endangering a
patient’s life.
During the course of any anesthetic, the patient’s ox-
ygenation, ventilation, circulation, and temperature
should be continuously evaluated. The concentration
of the inspired oxygen must be measured by an oxygen
analyzer. Assessment of the perioperative oxygenation
of the patient using pulse oximetry, now considered
mandatory in every case, has been a significant ad-
vancement in monitoring. This monitor is so critical to
the safety of the patient that it has earned the nickname
“the monitor of life”. Evaluation of ventilation includes
44 2 Anesthesia for Liposuction and Abdominoplasty
observation of skin color, chest wall motion, and fre-
quent auscultation of breath sounds. During general an-
esthesia with or without mechanical ventilation, a dis-
connect alarm on the anesthesia circuit is crucial. Cap-
nography, a measurement of respiratory end-tidal CO2,
is required, especially when the patient is under heavy
sedation or general anesthesia. Capnography provides
the first alert in the event of airway obstruction, hypo-
ventilation, or accidental anesthesia circuit disconnect,
even before the oxygen saturation has begun to fall. All
patients must have continuous monitoring of the elec-
trocardiogram (ECG), and intermittent determination
of blood pressure (BP) and heart rate (HR) at a mini-
mum of 5-min intervals. Superficial or core body tem-
perature should be monitored. Of course, all electronic
monitors must have preset alarm limits to alert physi-
cians prior to the development of critical changes.
While the availability of electronic monitoring
equipment has improved perioperative safety, there is
no substitute for visual monitoring by a qualified, expe-
rienced practitioner, usually a CRNA or an anesthesiol-
ogist. During surgeries using local with SAM, if a sur-
geon elects not to use a CRNA or an anesthesiologist, a
separate, designated, certified individual must perform
these monitoring functions [25]. Visual observation of
the patient’s position is also important in order to avoid
untoward outcomes such as peripheral nerve or ocular
injuries.
Documentation of perioperative events, interven-
tions, and observations must be contemporaneously
performed and should include BP and HR every 5 min
and oximetry, capnography, ECG pattern, and temper-
ature at 15-min intervals. Intravenous fluids, medica-
tion dosages in milligrams, patient position and other
intraoperative events must also be recorded. Docu-
mentation may alert the physician to unrecognized
physiological trends that may require treatment. Prep-
aration for subsequent anesthetics may require infor-
mation contained in the patient’s prior records, espe-
cially if the patient suffered an unsatisfactory outcome
due to the anesthetic regimen that was used. Treatment
of subsequent complications by other physicians may
require information contained in the records, such as
the types of medications used, blood loss or fluid totals.
Finally, compulsive documentation may help exonerate
a physician in many medical-legal situations.
When local anesthesia with SAM is used, monitor-
ing must include an assessment of the patient’s level of
consciousness as previously described. For patients un-
der general anesthesia, the level of consciousness may
be determined using the bispectral index (BIS), a mea-
surement derived from computerized analysis of the
electroencephalogram. When used with patients re-
ceiving general anesthesia, BIS improves control of the
level of consciousness, rate of emergence and recovery,
and cost-control of medication usage [281].
2.3.6
Fluid Replacement
Management of perioperative fluids probably generates
more controversy than any other anesthesia related
topics. Generally, the typical, healthy, 60-kg patient re-
quires about 100 cc of water per hour to replace meta-
bolic, sensible, and insensible water losses. After a 12-h
period of fasting, a 60-kg patient may be expected to
have a 1-liter volume deficit on the morning of surgery.
This deficit should be replaced over the first few hours
of surgery. The patient’s usual maintenance fluid needs
may be met with a crystalloid solution such as lactated
Ringer’s solution.
Replacement fluids may be divided into crystalloid
solutions, such as normal saline or balanced salt solu-
tion, colloids, such as fresh frozen plasma, 5 % albu-
min, plasma protein fraction, or hetastarch, and blood
products containing red blood cells, such as packed red
blood cells. Generally, balanced salt solutions may be
used to replace small amounts of blood loss. For every
milliliter of blood loss, 3 ml of fluid replacement is usu-
ally required [282]. However, as larger volumes of
blood are lost, attempts to replace these losses with
crystalloid reduces the serum oncotic pressure, one of
the main forces supporting intravascular volume. Sub-
sequently, crystalloid rapidly moves into the extracellu-
lar space. Intravascular volume cannot be adequately
sustained with further crystalloid infusion [283]. At
this point, many authors suggest that a colloid solution
may be more effective in maintaining intravascular vol-
ume and hemodynamic stability [284, 285]. Given the
ongoing crystalloid-colloid controversy in the litera-
ture, the most practical approach to fluid management
is a compromise. Crystalloid replacement should be
used for estimated blood losses (EBL) less than 500 ml,
while colloids such as hetastarch may be used for EBLs
greater than 500 ml. One milliliter of colloid should be
used to replace 1 ml of EBL [282]. However, not all au-
thors agree on the benefits of colloid resuscitation.
Moss and Gould concluded that isotonic crystalloid re-
placement, even for large EBLs, restores plasma volume
as well as colloid replacement [286].
For patients with less than 1,500 ml of fat extraction
using the tumescent technique, studies have deter-
mined that postoperative serum hemoglobin remains
essentially unchanged [287]. Therefore, intravenous
fluids beyond the deficit replacement and the usual
maintenance amounts are generally not required [19,
158, 287, 288]. As the volume of fat removed ap-
proaches or exceeds 3,000 cc, judicious intravenous flu-
id replacement, including colloid, may be considered,
depending on the patient’s hemodynamic status [19].
Fluid overload with the possibility of pulmonary ede-
ma and congestive heart failure following aggressive
administration of infusate and intravenous crystalloid

solutions has become a legitimate concern [158,
288 – 292]. Using the tumescent technique during
which subcutaneous infusion ratios are 2 – 3 ml for 1 ml
of fat aspirated, significant intravascular hemodilution
has been observed [289]. A 5-liter tumescent infusion
may result in a hemodilution of 10 %. Plasma lidocaine
near toxic levels, combined with an increased intravas-
cular volume, may increase the risk of cardiogenic pul-
monary edema, even in healthy patients [139].
While crystalloid replacement regimen may vary,
Pitman et al. [290] advocates limiting i.v. replacement
to the difference between twice the volume of total aspi-
rate and the sum of i.v. fluid already administered intra-
venously and as tumescent infusate. This replacement
formula presumes a ratio of infusate to aspirate of
greater than 2 to 1. If the ratio is less than one, more
generous replacement fluids may be required since hy-
povolemia may occur [291]. The determination of fluid
replacement is still not an exact science, by any means.
Because of the unpredictable fluid requirements in pa-
tients, careful monitoring is required, including possi-
ble laboratory analysis such as CBC, BUN [291].
The estimation of perioperative blood and fluid loss
during liposuction and abdominoplasty surgeries is
not a trivial task. Observers in the same room frequent-
ly have wide discrepancies in the estimated blood loss.
In the case of the abdominoplasty, unrecognized blood
loss occurs. Substantial amounts of blood typically
seep around and under the patient, unnoticed by the
surgeon, only to be discovered later as the nurses apply
the dressing. Because of subcutaneous hematoma for-
mation and the difficulty of measuring the blood con-
tent in the aspirate, estimating the EBL during liposuc-
tion may be a particularly daunting task. Fortunately,
the development of tumescent technique has dramati-
cally reduced perioperative blood loss during liposuc-
tion surgeries [24, 293].
The blood content in the aspirate after tumescent li-
posuction has varied between less than 1 % [288, 293]
and 8 % [290]. To underscore the difficulty of estimat-
ing the EBL, the range of the determined blood loss in
one study was 0 – 1,002 ml or 0 – 41.5 % of the aspirate
for liposuctions removing 1,000 – 5,500 ml of fat [290].
Samdal et al. [293] admitted that the mean fall of post-
operative hemoglobin of 5.2 % (±4.9 %) was higher
than anticipated. The author suggested that previous
estimates of continued postoperative blood extravasa-
tion into the surgical dead space may be too low and
may be greater than the EBL identified in the aspirate.
Mandel [294] concluded that unappreciated blood loss
continues for several days after surgery, presumably
due to soft tissue extravasation, and that serial postop-
erative hematocrit determinations should be used, es-
pecially for large volume liposuctions.
The decision to transfuse a patient involves multiple
considerations. Certainly, the EBL, health, age, and es-
2.3 Anesthesia for Liposuction and Abdominoplasty 45
timated preoperative blood volume of the patient, and
the hemodynamic stability of the patient are the prima-
ry concerns. The potential risks of transfusions, such as
infection, allergic reaction, errors in cross matching,
and blood contamination should be considered. Final-
ly, the patient’s personal or religious preferences may
play a pivotal role in the decision to transfuse. Cell sav-
ing devices and autologous blood transfusions may al-
leviate many of these concerns. Healthy, normovolemic
patients, with hemodynamic and physiologic stability,
should tolerate hemoglobin levels down to 7.5 g/dl
[295]. Even for large volume liposuction using the tu-
mescent technique, transfusions are rarely necessary
[19]. Once the decision to transfuse is made, 1 ml of
RBCs should be used to replace every 2 ml of EBL [282].
Serial hematocrit determination, although sometimes
misleading in cases of fluid overload and hemodilution,
is still considered an important diagnostic tool in the
perioperative period to assist with decisions regarding
transfusion.
During abdominoplasty and large volume liposuc-
tion monitoring the urine output using an indwelling
urinary catheter is a useful guide to the patient’s vol-
ume status. Urinary output should be maintained at
greater than 0.5 ml/kg per hour. However, urinary out-
put is not a precise method of determining the patient’s
volume status since other factors, including surgical
stress, hypothermia, and the medications used during
anesthesia are known to alter urinary output [296].
Therapeutic determinations based on a decreased uri-
nary output must also consider other factors, since oli-
guria may be a result of either hypovolemia or fluid
overload and congestive heart failure. In general, use of
loop diuretics, such as furosemide, to accelerate uri-
nary output, makes everyone in the room feel better,
but does little to elucidate the cause of the reduced uri-
nary output, and in cases of hypovolemia may worsen
the patient’s clinical situation. However, a diuretic may
be indicated if oliguria develops in the course of large
volume liposuction where the total infusate and intra-
venous fluids are several liters more than the amount of
aspirate [292].
The same intensive monitoring and treatment which
occurs in the operating room must be continued in the
recovery room under the care of a designated, licensed,
and experienced person for as long as is necessary to
ensure the stability and safety of the patient, regardless
of whether the facility is a hospital, an outpatient surgi-
cal center, or a physician’s office. During the initial
stages of recovery, the patient should not be left alone
while hospital or office personnel attend to other du-
ties. Vigilant monitoring including visual observation,
continuous oximetry, continuous ECG, and intermit-
tent BP and temperature determinations must be con-
tinued. Because the patient is still vulnerable to airway
obstruction and respiratory arrest in the recovery peri-
46 2 Anesthesia for Liposuction and Abdominoplasty
od, continuous visual observation is still the best meth-
od of monitoring for this complication. Supplemental
oxygenation should be continued during the initial
stages of recovery and continued until the patient is
able to maintain an oxygen saturation above 90 % on
room air.
The most common postoperative complication is
nausea and vomiting. The antiemetic medications pre-
viously discussed, with the same consideration of po-
tential risks, may be used in the postoperative period.
Because of potential cardiac complications, droperidol,
one of the most commonly used antiemetics, is now
considered unsafe unless the patient has no cardiac risk
factors and a recent 12-lead ECG is normal [68]. On-
dansetron (4 – 8 mg i.v. or s.l.) is probably the most ef-
fective and safe antiemetic. However, the cost of this
medication is often prohibitive, especially in an office
setting. Postoperative surgical pain may be managed
with judiciously titrated i.v. narcotic medication such
as demerol (10 – 20 mg i.v. every 5 – 10 min), morphine
(1 – 2 mg i.v. every 5 – 10 min), or butorphanol
(0.1 – 0.2 mg i.v. every 10 min).
Following large volume liposuction, extracellular
fluid extravasation or third spacing may continue for
hours postoperatively leading to the risk of hypoten-
sion, particularly if the ratio of tumescent infusate to
aspirate is less than one [292]. For large volume lipo-
suction, blood loss may continue for 3 – 4 days [294].
Crystalloid or colloid replacement may be required in
the event of hemodynamic instability.
The number of complications that occur after dis-
charge may be more than twice the complications oc-
curring intraoperatively and during recovery com-
bined [297]. Accredited ambulatory surgical centers
generally have established discharge criteria. While
these criteria may vary, the common goal is to ensure
the patient’s level of consciousness and physiological
stability. Table 2.8 is one example of discharge criteria
that may be used:
Table 2.8. Ambulatory discharge criteria. (Modified from Mecca
[298])
1 All life-preserving protective reflexes, i.e., airway, cough,
gag, must be returned to normal
2 The vital signs must be stable without orthostatic
changes
3 There must be no evidence of hypoxemia 20 min after
the discontinuation of supplemental oxygen
4 Patients must be oriented to person, place, time, and sit-
uation (times 4)
5 Nausea and vomiting must be controlled and patients
should tolerate p.o. fluids
6 There must be no evidence of postoperative hemorrhage
or expanding ecchymosis
7 Incisional pain should be reasonably controlled
8 The patient should be able to sit up without support and
walk with assistance
Use of medication intended to reverse the effects of
anesthesia should be used only in the event of suspect-
ed overdose of medications. Naloxone (0.1 – 0.2 mg i.v.),
a pure opiate receptor antagonist, with a therapeutic
half-life of less than 2 h, may be used to reverse the re-
spiratory depressant effects of narcotic medications,
such as morphine, demerol, fentanyl, and butorphanol.
Because potential adverse effects of rapid opiate rever-
sal of narcotics include severe pain, seizures, pulmo-
nary edema, hypertension, congestive heart failure,
and cardiac arrest [299], naloxone must be adminis-
tered by careful titration. Naloxone has no effect on the
actions of medications, such as the benzodiazepines,
the barbiturates, propofol, or ketamine.
Flumazenil (0.1 – 0.2 mg i.v.), a specific competitive
antagonist of the benzodiazepines, such as diazepam,
midazolam, lorezepam, may be used to reverse exces-
sive or prolonged sedation and respiratory depression
resulting from these medications [300]. The effective
half-life of flumazenil is l h or less [301].
The effective half-lives of many narcotics exceed the
half-life of naloxone. The benzodiazepines have effec-
tive half-lives greater than 2 h and, in the case of diaze-
pam, up to 50 h. Many active metabolites unpredictably
extend the putative effects of the narcotics and benzo-
diazepines. A major risk associated with the use of nal-
oxone and flumazenil is the recurrence of the effects of
the narcotic or benzodiazepine after 1 – 2 h. If the pa-
tient has already been discharged to home after these
effects recur, the patient may be at risk for oversedation
or respiratory arrest [299, 302]. Therefore, routine use
of reversal agents, without specific indication, prior to
discharge is ill advised. Patients should be monitored
for at least 2 h prior to discharge if these reversal agents
are administered [25].
Physostigmine (1.25 mg i.v.), a centrally acting anti-
cholinesterase inhibitor, functions as a non-specific re-
versal agent which may be used to counteract the agita-
tion, sedation, and psychomotor effects caused by a va-
riety of sedative, analgesic, and inhalation anesthetic
agents [303, 304]. Neuromuscular blocking drugs, if re-
quired during general anesthesia, are usually reversed
by the anesthesiologist or CRNA prior to emergence in
the operating room with anticholinesterase inhibitors
such as neostigmine or edrophonium. Occasionally, a
second dose may be required when the patient is in the
recovery room.
In the event patients fail to regain consciousness
during recovery, reversal agents should be adminis-
tered. If no response occurs, the patient should be eval-
uated for other possible causes of unconsciousness, in-
cluding hypoglycemia, hyperglycemia, cerebral vascu-
lar accidents, or cerebral hypoxia. If hemodynamic in-
stability occurs in the recovery period, causes such as
occult hemorrhage, hypovolemia, pulmonary edema,
congestive heart failure, or myocardial infarction must

be considered. Access to laboratory analysis to assist
with the evaluation of the patient is crucial. Unfortu-
nately, stat laboratory analysis is usually not available if
the surgery is performed in an office-based setting.
The above text is meant to serve as an overview of
the extremely complex subject of anesthesia. It is the in-
tent of this chapter to serve as an introduction to the
physician who participates in the perioperative man-
agement of patients and should not be considered a
comprehensive presentation. The physician is encour-
aged to seek addition information on this broad topic
through the other suggested readings. At least one au-
thoritative text on anesthesia should be considered a
mandatory addition to the physician’s resources.
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